What is the management approach for severe preeclampsia postpartum in a hospital setting?

Postpartum Severe Preeclampsia Hospital Management

For severe preeclampsia postpartum, initiate magnesium sulfate prophylaxis for at least 24 hours, aggressively treat blood pressures ≥160/110 mmHg with IV antihypertensives, monitor blood pressure every 4-6 hours for at least 3 days, and continue close surveillance with serial laboratory testing until clinical stability is achieved. 1, 2

Immediate Seizure Prophylaxis

Magnesium sulfate is mandatory for all women with severe postpartum preeclampsia. 3, 2

• Administer a loading dose of 4-5 g IV over 3-4 minutes (diluted to 10-20% concentration) or 4 g IV plus 10 g IM (5 g in each buttock) 3, 2
• Follow with maintenance infusion of 1-2 g/hour IV or 4-5 g IM every 4 hours 3, 2
• Continue for at least 24 hours postpartum, as eclampsia can still develop during this critical period 3, 1, 2
• Monitor patellar reflexes before each dose—if absent, hold magnesium until reflexes return 2
• Ensure urine output >100 mL per 4 hours before each dose 2
• Target therapeutic serum magnesium level of 4-6 mg/dL (optimal for seizure control is 6 mg/100 mL) 2
• Have IV calcium gluconate immediately available to reverse magnesium toxicity 2

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

Treat urgently in a monitored setting to prevent cerebrovascular complications. 3, 1

First-line IV options: 3, 1, 4

• Labetalol: 20 mg IV bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes (maximum 220 mg total) 4
• Hydralazine: IV administration per protocol 3, 1
• Nicardipide: IV infusion 1

Oral option (if IV not immediately available): 3, 4

• Nifedipine: 10 mg orally, repeat every 20 minutes to maximum 30 mg 4

Critical warning: Never use sublingual nifedipine due to risk of precipitous blood pressure drops causing myocardial infarction or fetal compromise 4

Non-Severe Hypertension (≥140/90 mmHg but <160/110 mmHg)

Target diastolic BP of 85 mmHg and systolic BP 110-140 mmHg (or at minimum <160 mmHg systolic). 3, 1, 4

Preferred oral agents (safe for breastfeeding): 3, 1

• Labetalol
• Nifedipine (extended-release)
• Methyldopa

Reduce or cease antihypertensives if diastolic BP falls <80 mmHg. 3

Monitoring Protocol

Blood Pressure Surveillance

• Monitor BP every 4-6 hours while awake for at least 3 days postpartum 1
• More frequent monitoring (every 4 hours or more) if severe features present 4
• Maintain systolic BP <160 mmHg and diastolic BP <110 mmHg to prevent cerebrovascular complications 1

Laboratory Monitoring

Repeat hemoglobin, platelets, creatinine, and liver transaminases: 1

• The day after delivery
• Every second day until stable if any were abnormal before delivery
• At least twice weekly in most women with ongoing preeclampsia 3

Clinical Assessment

Assess for signs of worsening preeclampsia at each evaluation: 1

• Severe headache or visual disturbances (neurological symptoms)
• Right upper quadrant or epigastric pain
• Clonus 3
• Respiratory status (ensure ≥16 breaths/minute) 2

Fluid Management

Strictly limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema. 4

• Aim for euvolemia—avoid "running dry" as this increases acute kidney injury risk 4
• Diuretics are contraindicated in preeclampsia as they further reduce plasma volume 4
• Plasma volume expansion is not recommended 3

Discharge Planning

Most women can be discharged by postpartum day 5, especially when they can monitor BP at home. 1

Before discharge, ensure: 1

• Blood pressure adequately controlled on oral medications
• Patient educated on home BP monitoring
• Clear instructions to report severe headache, visual changes, or right upper quadrant pain
• Antihypertensive medications prescribed with breastfeeding considerations 1

Continue antihypertensives postpartum and taper slowly only after days 3-6, unless BP becomes low or patient symptomatic. 1

Follow-up Requirements

• Review at 3 months postpartum to ensure BP, urinalysis, and laboratory tests have normalized 1
• Refer to specialist if hypertension or proteinuria persists at 6 weeks postpartum 1

Long-term Counseling

Counsel all women about future risks: 1

• Approximately 15% risk of recurrent preeclampsia in future pregnancies 1
• 15% risk of gestational hypertension in future pregnancies 1
• Increased lifetime risks of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease 1

Critical Pitfalls to Avoid

• Never combine IV magnesium with calcium channel blockers due to myocardial depression risk 4
• Do not use magnesium sulfate beyond 5-7 days as continuous administration can cause fetal abnormalities (if still pregnant) or toxicity 2
• Avoid ACE inhibitors if breastfeeding considerations require alternative agents 4
• Do not discharge prematurely—most postpartum preeclampsia presents within the first 7-10 days after delivery, frequently with neurologic symptoms 5
• Extended monitoring with strict BP goals (<150/<100 mmHg) before discharge has not been shown to reduce readmissions and may paradoxically increase them 6